Avoiding Corticosteroids' Serious Side Effects

PHILADELPHIA, Nov. 16 -- Corticosteroid medications are not without the risks of serious side effects, but there are ways to avoid or minimize them.

Clinicians outlined strategies to reduce risk in presentations at a symposium held here in conjunction with the American College of Allergy, Asthma & Immunology. The symposium was sponsored by Altana Pharma U.S., Inc. of Florham Park, N.J.

One of the best known and most worrisome side effects of inhaled corticosteroids (ICS), used to treat asthma, is stunted growth in children, said David B. Allen, M.D., of the University of Wisconsin in Madison.

The most important way to try to avoid this adverse effect is to titrate children to the lowest effective dose of ICS, Dr. Allen said. Physicians should also remember that newer formulations of corticosteroids are more potent and should not be prescribed at the old dosages.

The portion of the inhaled drug that does not make it into the lung but is instead swallowed, and the ensuing systemic effect interferes with the growth process. Therefore, physicians should choose drug formulations with low oral bioavailability, Dr. Allen said.

Night doses of steroids should be avoided, as nighttime is when children's growth systems are most active, Dr. Allen said.

Physicians should also keep in mind that, while compliance with ICS is generally poor in the long-term, children who conscientiously take their medicine will be at the greatest risk for slowed growth, Dr. Allen said. These children should be vigilantly monitored, he said.

Finally, it is important to persuade parents that managing a child's asthma, which is a potentially life-threatening disease, is worth the risk of slowed growth. "Parents have an unrealistic fear about what the medicine will do to kid's growth," Dr. Allen said. "Reassure them that the lowest dose will be used and that their child will be carefully monitored."

For patients on oral corticosteroids, another serious potential side effect is suppression of the hypothalamic-pituitary-adrenal (HPA) axis, which can lead to adrenal insufficiency, said Serge A. Jabbour, M.D., of the Thomas Jefferson University here.

Patients at high risk for HPA suppression include those with Cushingoid appearance, those who have received daily doses of more than 20 mg of prednisone (sold under a variety of brand names) for more than three weeks, and those who have received an evening dose of prednisone for more than three weeks, Dr. Jabbour said.

Patients in whom HPA suppression is unlikely include those who have been on steroids less than three weeks and those who are taking less than 5 mg of prednisone daily-provided the drug is not taken in the evening, Dr. Jabbour said.

Another strategy for avoiding ICS side effects is creating a prodrug that is converted to an active state in the lung tissue, thereby bypassing the dangers of swallowing a portion of the drug, said Dr. Hartmut Derendorf, M.D., Ph.D., of the University of Florida in Gainesville.

One such prodrug product is available, Dr. Hartmut noted: Omnaris (ciclesonide). This nasal spray was approved just last month by the FDA for treating allergic rhinitis in adults and children 12 and older.

Altana Pharma U.S., Inc., which sponsored the symposium, is the maker of Omnaris.